MEDICARE: DR. IRINA GROMOV MD, PH.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2084P0802X	Addiction Psychiatry Physician	L4407	TX
2	2084P0800X	Psychiatry Physician	L4407	TX

General Provider Information

NPI Number	:	1831131150
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. IRINA GROMOV MD, PH.D.

Provider Business Mailing Address
First Line	:	8222 DOUGLAS AVE STE 375
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75225-5973
Country	:	US
Telephone Number	:	214-905-5090
Fax Number	:

Provider Business Practice Location Address
First Line	:	8222 DOUGLAS AVE
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75225-5923
Country	:	US
Telephone Number	:	214-905-5090
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/12/2006
Last Update Date	:	10/04/2007

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